Provider Demographics
NPI:1922260587
Name:MUSICK DERMATOLOGY & ADVANCED CLINICAL SPA, LLC
Entity Type:Organization
Organization Name:MUSICK DERMATOLOGY & ADVANCED CLINICAL SPA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DORIS
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:GLAUBER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-628-2588
Mailing Address - Street 1:4948 BENCHMARK CENTRE DR
Mailing Address - Street 2:
Mailing Address - City:SWANSEA
Mailing Address - State:IL
Mailing Address - Zip Code:62226-2027
Mailing Address - Country:US
Mailing Address - Phone:618-628-2588
Mailing Address - Fax:618-628-1363
Practice Address - Street 1:4948 BENCHMARK CENTRE DR
Practice Address - Street 2:
Practice Address - City:SWANSEA
Practice Address - State:IL
Practice Address - Zip Code:62226-2027
Practice Address - Country:US
Practice Address - Phone:618-628-2588
Practice Address - Fax:618-628-1363
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-25
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089938207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty